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Dr Ramana Alladi: SAS Doctors

Dr Ramana Alladi was Chair of the AAGBI’s SAS Committee for nine years and has been very active in promoting training and career opportunities for nonconsultant career-grade doctors. Originally from India, he arrived in Britain in 1975 as a surgical trainee and initially took a six month post in anaesthetics while studying for his surgical exams. He has since been involved in education with the Association and Royal College of Anaesthetists, and has been on the Council of both institutions.

In this interview, Dr Alladi discusses his experiences and the problems he faced as an SAS doctor throughout his career. For the full interview transcript, click here.

SAS Grade

When it started a long time ago, we were known as ‘non-consultant career-grade doctors’. The reason why we started to use ‘SAS doctors’ was that traditionally by British Medical Association this group of doctors were called SAS doctors because the only grades that were recognised nationally, according to national terms and conditions, were staff grade and associate specialist.

There are many reasons why people get into SAS grades. Number one, people don’t want to do postgraduate exams, but yet they want to work in the speciality. And the only opening you have here in this part of the world is to become an SAS doctor. And people did exams but were not successful, but still they want to continue as anaesthetists.

“I think this is going to be an increasingly popular grade…”

Most of the doctors who came from overseas had to take these SAS grade jobs because they are qualified and have the post-graduate qualifications abroad, most of them. They did a survey and about 75% of the people who are working here are MDs from wherever they came from. So going by my example, they could not get onto the higher professional training, so they have to take up these jobs. We are talking about doctors between 40, 45 kind of thing. That’s not the time to change a speciality. Some people reluctantly became general practitioners and could do clinical assistant sessions in hospitals and it was allowed then. I don’t think it will be now because of the revalidation and so on. Another thing is they’ve got families and children going to schools, they don’t want to move around looking for further progression and so on, and again this is the only opening they have.

I think increasingly this is going to be a very popular grade because of various reasons, because the new generation of doctors, even my kids, they say they don’t mind being an SAS doctor, having got all this experience, because they have got other things to do in their lives and they don’t want to be spending all their time being a doctor. So there are some people who want to work part-time because they want to go abroad, work in Africa, Australia, do public health, that sort of thing, and there is no provision for that kind of thing in the present training schemes. If you miss out on the regular programme you lose your number and you’ve had it, see? So they are going to take up SAS grades because there may not be that kind of restrictions, you can come and go.

Medical School

My father was a doctor. I am the youngest of the ten and six of us are doctors in our family. I remember my mother telling me once when I was very young, ‘If you become a doctor, you can go anywhere in the world, sit under a tree, give an injection and get money for it. So job won’t be a problem.’ And then I saw my father and my brothers and sisters very well-respected in society… they were working 24/7 so to speak, but they seemed to enjoy what they were doing.

“I had a fancy for the stethoscope and the white coat”

And thirdly, I had a fancy for the stethoscope and the white coat and the bleep and so on. And one of my sisters said I also… wanted to wear spectacles. This is about when I was eight or nine years old, so all these things appealed to me.

I went to a medical school in South India, in Andhra Pradesh and qualified in 1971. I wanted to be a general surgeon, but actually I did surgery for eight years, even in this country, I was a surgical registrar for a year [and] I’ve done my fellowship, my FRCS. I completed it while I was just doing SHO job in anaesthesia.

“My family didn’t appreciate my change of career… they were very cross that I changed to an inferior speciality…”

The story of how I got into anaesthetics was I was preparing for my surgical fellowship in a hospital and I was studying in the library every day, and this consultant anaesthetist happened to see me, and he made a proposal. He said, ‘We’re short of anaesthetists, we will give you a job for six months, three months you don’t have to work. [We’ll] give you study leave and teach you how to do anaesthetics. You won’t be put on call, but I would like you to work for six months for us.’ And I got into anaesthetics when I instantly fell in love with it.

I’m sorry to say that my family didn’t appreciate my change of career at all. They thought, in those days anaesthetists were playing second fiddle to the surgeons, and especially my sisters were very cross that I changed it to an inferior speciality, so to speak, which I don’t believe at all… I thought there was a great future for the speciality because of the introduction of the intensive care and also I like doing procedures, doing things with my hands. For various reasons I thought anaesthetics is the appropriate thing for me.

Arrival in England

I came to England on my own in 1975. I’d never been abroad. I didn’t have any friends, nor relatives, and my first job was in a place called Law Hospital, Carluke in Lanarkshire, in A&E. In those days we had to do what we called Clinical Attachment for two weeks and the consultant you were under, he would look at you and then say if you are good enough to go onto registration, so I took all the risks and one of my sisters financed my trip and yes, luckily after one week the consultant thought I was good enough and I joined that place as an SHO in orthopaedics and casualty. I was still studying surgery at the time.

“I came to England on my own… I’d never been abroad. I didn’t have any friends, nor relatives”

In those days I worked here as a senior SHO and [there were] no prospects unfortunately for overseas doctors to get into professional training, and I wanted to stay here and do something really constructive, not just do the exam. Before I came here I did neurosurgery and cardiothoracic surgery, and I did burns and plastic in a major burns unit in Birmingham Accident Hospital. My main ambition at that time was to be a trauma surgeon, so I did all these specialities that are useful like orthopaedics, vascular, plastics and cardiac.

I worked for 1.5 years in Lanarkshire and then I did six months in Loch Lomond. I loved it because it’s a beautiful place, and because I had this desire to continue on in trauma thing, I worked in Coleraine Hospital in Northern Ireland, and there the general surgical department. I was a Casualty Officer when the Ballymoney bomb took place in ’76 so I had to admit at least 40 patients… I still remember two or three patients who were admitted to the intensive care unit with the blast injury, lungs, they left after I left six months later, so I had the whole experience I was looking for in trauma in one day!

“I was a Casualty Officer when the Ballymoney bomb took place…”

I started in Darlington Memorial Hospital, where I was trying to do my surgery, and then I got a job in Whittington Hospital as a locum SHO to start with. At the time it was a problem: I had to defend myself, why I want to do anaesthetics, and I was always found to be overqualified for whatever job I applied for. And because I’d been doing SHO jobs till then, for nearly four years, I thought I was a little bit stuck, and then after working as an SHO in Whittington Hospital I was appointed as a registrar in Wigan, Royal Albert Infirmary, and I worked there for four years and I got my Fellowship right at the end of the registrarship.

Once again I was stuck because I had all this experience and I was doing all the major anaesthetics, in those days registrars used to do whatever… I still remember when I applied for higher permission training job, one of these guys told me, ‘I can get you a job in Johns Hopkins but I’m afraid to give you a job. We’ve got our people to do these jobs. Why do you want to come here?’ And I told him that now I’m married – at the time I’d just got married and got two children, and told him I love this place and I think I’m entitled to be here… [it] may not be appropriate for the interview, but because he asked me I had to give a piece of my mind.

“I can get you a job, but I’m afraid… We’ve got our own people to do these jobs…”

If you are an overseas doctor it’s rather difficult because of the age and qualifications I couldn’t support myself, but some of my colleagues who are working in the teaching hospitals, they had connections I guess, and they managed to get onto this higher personal training. So, I did try and I couldn’t.

Senior RMO

Well, I was really too stuck and I wanted to be in England… they’d just opened a private hospital near Stockport, it’s called Alexander Hospital, where they were doing open surgery in private sector. They wanted an anaesthetist who was trained to look after the intensive care and so on, as an RMO [resident medical officer]. So I just had to leave NHS and I took a very risky move to be a senior RMO at the Alexander Hospital in Cheadle. And I worked there for nearly five years.

As Senior RMO you admit patients, take their concerns and give night sedations and put up the drips and that sort of thing, but they wanted me because when we do open heart or anybody who was very ill then the consultants had confidence that I was there, I could take them to theatre, I could take an open heart surgery fail, take them to theatre while they are waiting for the anaesthetist to come. But again I was stuck. That’s not what I was looking for at the time.

I was giving locum anaesthetics at the same time and I probably worked in about 15 different hospitals. I was approached by the anaesthetist from Tameside Hospital one day and he said, ‘We are going to look for somebody to look after our intensive care unit. You’ve got a lot of experience and none of our consultants are trained to do it. Would you mind coming as a clinical assistant?’. I said to them that I would come if I was appointed as an Associate Specialist rather than a clinical assistant, and this particular doctor went out of the way to recommend my name. And I got the job, 1991, and I stayed there until I retired. I was supposed to look after the intensive care to start with, under the supervision of consultants, and I started doing [it] independently. All the five days I was doing this and every third night on call, resident on call.

I designed some drug studies, which I proposed and when I took it to the professors in Manchester, they said it’s not good enough… And in three weeks’ time, you’d see one of the senior registrars doing it.

The SAS Committee

I joined the Association of Anaesthetists’ Committee in 2002. I was contacted by Dr Kate Bullen, who was the elected SAS member on the Council of the Association. I think I happened to write an article about SAS issues in Anaesthesia News, and she was in the process of forming an SAS committee and asked whether I would be interested in being a member. At that time it was called Non-Consultant Career-Grade Committee. I’ve been the chairman since 2003. I would think I’ve been able to make things a bit better from the accolade I got from the Association. My main aim was to raise the profile of SAS doctors and make their lives in the hospitals better.

“I think I helped quite a few SAS doctors to get fellowship jobs or some deputation… Quite a few people I helped got accredited eventually”

That’s one of the reasons why I wanted to get onto the Postgraduate Medical Education Training Board: it was virtually impossible to get accredited, even though they created another pathway, and to become a consultant was extremely difficult. I tried to change the whole structure so that it’s slightly easier, now [it’s] possible. For example, a lot of people are failing in one or two specialities, like paediatrics, surgery or pain management, that sort of thing. And SAS doctors working already, they couldn’t get experience in those specialities, which means that they have to leave the jobs and go somewhere, while families are ruined. So it wasn’t easy. So like that I think I probably helped quite a few SAS doctors to get them these fellowship jobs or some deputation, that sort of thing. Quite a few people I helped to get accredited eventually.

I left the Chair of the SAS Committee in 2015 and stopped giving anaesthetics in October last year. I’m not retired really because now I am the Education Programme Advisor for the Royal College of Anaesthetists, so I am responsible for most of the meetings next two or three years. I’m on all the CPD Board, Education Board, learning webcast. Because I’m not giving anaesthetics I have to fill ten sessions!

When I was on the Education Committee of the Association, I started organising seminars on my own. I have had my own meeting, Manchester Core Topics, which I’ve done for the last ten years. There’s always been an argument that SAS doctors should be treated as consultants. They don’t need to have meetings exclusively, but also they’ve got different issues, so what I did was SAS-specific seminars and also an SAS session in the Annual Congress every year. Before I’d been elected to the council for the Royal College of Anaesthetists, I used to run the Joint Review Days for SAS doctors, and also I’m very proud of one of the meetings I’ve done, a three-day meeting for SAS doctors in the British Medical Association, attended by at least 300 people.

There was a time, a short period, when I was on the Councils for both the Royal College and the Association. And then I thought there would be a conflict of interest, so I couldn’t concentrate on either of those.

In 2014 the AAGBI awarded me honorary membership, the Anniversary Medal and the Council Medal as well.

Retirement

I’ve been running an acupuncture clinic for chronic pain for the last 12 years with one session I do for 10-12 patients. I’ve been doing that continuously, and then last month at the end of May I stopped it altogether. It’s because I’m 68 going on 69 this month, and also my daughter gave birth to a baby daughter. So I thought it’s time to enjoy myself.

I’ve got two children, a son and daughter, both doctors. My daughter did medicine in Cambridge, she’s been doing paediatric training in London, and she also worked with Wendy Reid as a clinical fellow after she came to be Director of the NHS England. Now she’s being a mother. She’s quite happy.

“It’s time to enjoy myself!”

And my son also did medicine in Cambridge, and he became a professional actor now. He’s done a lot of productions in high school and in Cambridge, he did a course in LAMDA as well. And now he’s done a few dramas in National Theatre.

He still works every now and then as a locum in A&E, but he tells me his heart is in drama. When I watched him… he’s a different person when he’s on the stage… I think you have to follow where your heart is. Probably in my case, my people wanted me and I also wanted to be a surgeon, to start with, but I got into anaesthetics, which I love it immensely, so I’m very lucky that I got into anaesthetics.

To relax, I write poetry, and especially in my mother tongue, Telugu. I published a book of poetry recently. What I did was when I stopped doing anaesthetics I had a lot of time so I started addressing and putting down my thoughts and it’s being published. I’m writing my experiences here in anaesthesia and in the country, and I’ve taken up a project: one of my grandfathers is a quite famous man, he wrote an autobiography in Telugu and he is really well known for his political science and things. And one of the second generation people who are living abroad, they wanted me to translate because I know both Telugu and English, so I’ve been translating that book into English. That’s a very big project. It’s about 400 pages. I’m about to finish actually.

I’ve got three folders of writing now. One I’m writing about anaesthetists, with lots of little silly things that we do which have got no clinical evidence. Say for example we gave gallons of normal saline when we were students. Nowadays it’s the wrong solution to give. Like that antiseptic- I probably would just wash my hands with soap and operated and nothing seemed to happen. Now they’re talking about different kinds of antiseptics and how we apply and this and that, and especially infection risk.

“There’s so much we could improve in the NHS if only we had control”

The other thing is lots of things we can improve. I mean in the NHS for example we talk about productivity, efficiency and that sort of thing, but when we go to hospital, there are no beds, and a basic need for a productive day is having enough beds and efficient people to do things. I remember writing an article to Anaesthesia News about 101 things that can go wrong kind of thing. It was taken up by the NHS Quality Management people and they asked me to do a workshop. We did lots of things without any … there was a time we used to give prophylactically blood transfusion for hips, even before we started. And how things have changed and why we did it and what clinical evidence you have at that particular moment, how we agreed to these things… I’m writing down all that kind of thing.

The other thing is in general NHS I think there’s so much we can do it improve if only we had control. A lot of non-medical people will come in [and] they have theories but no real understanding of what goes on in the field. That’s my personal view. So writing that down, doing that kind of thing.

And there are lots of cultural nuances for patients when they come here… the expressions they make and thank you, sorry, excuse me kind of thing… I’m listing them out and trying to explain why they are like that. They are seen as disrespectful gestures but that’s the way they are and they don’t tend to thank people for anything, they take it for granted, and they interrupt, it’s taken as rudeness, so there’s lots of these cultural nuances. So all these things I want to … just educate people really because they don’t know.

Reflections

As to being disadvantaged by race, I would say yes and no, because if you were in the right place with a good network and that sort of thing … a lot of Asians became consultants of my generation, and I failed to become one. As I mentioned before, that’s because they were working in teaching hospitals and there were some gaps… I think that’s one thing. I don’t think … there are no openings for SAS doctors. I mean now the problem is with career progress and development of SAS doctors, I think traditionally the SAS doctors had low esteem, they were not recognised for the talents they have.

“I think traditionally the SAS doctors had low esteem, they were not valued for the talents they have”

But again I don’t say there’s been any racial reasons for it. Just that there are no avenues open for people who are experienced, slightly aged and there are only limited spaces in training and I can see any employer would like to take a younger one. To give a typical example now, people who have got accredited with the specialist register, 55-year-olds … about 35% of them can’t get consultant jobs. They have been accredited and all that. Because the employers prefer somebody who’s 35 or 40 I guess.

But in my case, yes I have been badly done in earlier days. I explained to you my experience and I explained to you my qualifications and why couldn’t I get a place? It’s not a lack of trying. A lot of people at that time went to America or Middle East… but I loved the place where I lived all these years… and for my family I wanted to be in one place and I wanted my children to have a sense of belonging to the place. So I won’t call it a sacrifice but I suppose that’s the best thing for me to do.

“The greater the risks you take and the greater the sacrifice you make, the more successful you are and much better person you are”

I remember when I was working as an RMO in the private hospital, one of the chaps was doing heart transplants they were getting very popular between ’80 and ’85, by ’85 or ’90, and he told me repeatedly that, ‘Whatever you do, don’t become a cardiac anaesthetist, you won’t have a family life. Look at me, I have to NHS work, private work and then heart transplants come up any time.’ And he repeatedly told me and convinced me. But I over the years made it a point that I remembered that, because he didn’t see the children growing up, but I always took my children to schools and whenever possible I was always there to collect them. Even now I tell the registrars and other colleagues that’s very important that you should not miss out on your children growing up, and my children used to come and tell me their friends whose parents were doctors would always say, ‘How come your dad is always here?’ I… somehow managed … I try and not miss out on family life.

What I realised from my life is that the greater the risks you take and the greater the sacrifice you make, the more successful you are, and much better person you are. If I were to live in for example India, I would be extremely popular, my family was very well known, I wouldn’t have encountered any of these problems. Because I came abroad, I lived on my own, I know how to assert myself and I went through all these things, some of them maybe crises but at the same time I manoeuvred myself through it. For that I think I am a better person. It definitely got me confidence. And also in life I realise that you don’t have control of your destiny. You have to do what is presented to you at that particular time and make the best of it.